Use the form below to sign up for LaGrange Piano Summer Classes! Summer Programs Sign Up 2021 Parent/Guardian Name * First Last * Last Email Address * Phone Number * Student Information Student's Name * First Last * Last Birthdate * Any Allergies * Yes No Please list all allergies * Summer Drama Program: Willy Wonka KIDS - sold out! $150/student June 14th - 18th: 9am - 1pm June 18th: 6pm SHOW! June 19th: 2pm SHOW! Ages 6-13 Jedi Journey Music Class $95/student June 2nd - 4th: 10am - 12pm Ages 6-12 Sewing Class $50/student June 28th - 29th: 10am - 11:30am Ages 8 and up Art Camp $100/student July 7th - 9th : 9am - 12pm Ages 6 and up Jewelry Making Class $50/student June 24th - 25th: 10am - 12pm Ages 8 and up plus1 Add Another Student minus1 Remove Student Emergency Contact Information Emergency Contact Name * First and Last Emergency Contact Phone Number * Permission Slip Please download the permission slip, fill it out, and bring it with you on the first day. DOWNLOAD HERE Photo and Video Release * Yes No Please ask on a case-by-case basis Does the instructor have permission to feature photos and/or videos of this student (never using full last name) on the studio bulletin board, website, Facebook page, and/or promotional items? Refunds:I understand that if I must drop out of the program before June 13th, I will only receive a maximum of $140 per student due to processing fees. I understand that after June 13th, no refunds will be given. * I understand and agree. Total Cost This is the total cost for your camper and camp selections. Credit Card * Credit Card Credit Card Credit Card Month 123456789101112 Credit Card Year 20242025202620272028202920302031203220332034 Credit Card Billing Address * Billing Address Billing Address Billing Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Submit
